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10 Problems and Solutions for Positional Therapy: Technical Aspects of the Sleep Position Trainer
Abstract
Half of the OSAS patients are position dependent and Positional Therapy has proven to be effective in treating POSAS. Several research studies report positive results on the AHI, but discomfort and consequent disruption of sleep architecture have been responsible for poor compliance and subsequent disappointing long-term results of these interventions. This chapter focuses on the ten most important problems with traditional Positional Therapy, identified in research and user testing, causing its poor compliance and effectiveness. In addition, every paragraph reasons how these elements could be solved in an effective and comfortable manner. The ten problems are split up in effectiveness issues (1, 2, and 3) and compliance issues (4”“10). For each one, solutions are suggested based on previous research and literature. All solutions are integrated in the Sleep Position Trainer, an innovation for Positional Therapy.
Dental sleep appliances achieve a 50% response in around 65% of patients with obstructive sleep apnea and a complete response in 35–40%. This means that all practitioners will need to augment the effect of a dental sleep appliance at some stage. There are many ways in which adjunctive therapies can be used to augment both the objective and subjective outcomes of DSA therapy. This chapter discusses the use of multiple adjunct therapies including positional therapies, positive airway pressure therapies, therapies aimed at stabilizing or improving compromised anatomy in the upper airway, and therapies aimed at improving the subjective outcomes of sleep.KeywordsDental sleep applianceObstructive sleep apneaPositional obstructive sleep apneaCognitive behavioral therapy for insomniaCircadian rhythm disordersBright light therapyOral EPAPNasal EPAP
First-line therapy for patients with moderate to severe obstructive sleep apnea (OSA) is positive airway pressure (PAP). Although PAP is a highly efficacious treatment, adherence to PAP is still a substantial clinical problem. The objective of this study was to determine whether PAP adherence can be improved with a telemedicine monitoring system.
A nonblinded, single-center, randomized controlled trial that compared standard PAP treatment versus PAP treatment and a telemedicine monitoring system
University sleep disorders program in British Columbia, Canada
Adult patients (≥ 19 yr of age) with moderate to severe OSA (apnea hypopnea index (AHI) ≥ 15 events/hr determined by polysomnography) prescribed PAP INTERVENTIONS: Patients were randomized to either standard care with an autotitrating PAP machine or an autotitrating PAP machine that transmitted physiologic information (i.e., adherence, air leak, residual AHI) daily to a website that could be reviewed. If problems were identified from information from the website, the patient was contacted by telephone as necessary.
PAP adherence after 3 mo, subjective sleep quality, and side effects
Seventy-five patients were enrolled; 39 were randomized to telemedicine and 36 to standard care. The mean age ± standard deviation (SD) was 53.5 ± 11.2 yr, mean AHI was 41.6 ± 22.1 events/hr, and 80% of patients were male. After 3 mo, mean PAP adherence was significantly greater in the telemedicine arm (191 min per day) versus the standard arm (105 min per day; mean difference = 87 min, 95% confidence interval (CI): 25-148 min, P = 0.006, unpaired t test). On days when PAP was used, mean adherence was 321 min in the telemedicine arm and 207 min in the standard arm (difference = 113 min, 95% CI: 62-164 min, P < 0.0001). Significant independent predictors of adherence included age, baseline Epworth Sleepiness Scale score, and use of telemedicine. On average, an additional 67 min of technician time was spent on patients in the telemedicine arm compared with the standard arm (P = 0.0001).
PAP adherence can be improved with the use of a web-based telemedicine system at the initiation of treatment.
Vibrotactile threshold (VT) testing has been used for nearly a century to investigate activation of human somatosensory pathways. This use of vibrotactile stimuli provides a versatile tool for detecting peripheral neuropathies, and has been broadly used for investigation of carpal tunnel syndrome. New applications include investigation of drug-induced neuropathies and diabetes-related neuropathies. As a feedback device, the vibrotactile stimuli could be used as an information delivery system for rehabilitative feedback devices for upper limb musculoskeletal disorders or as information channels for the visually impaired. This review provides a comprehensive review of the advancement in VT measurement techniques over time and a comparison of these techniques in terms of various hardware features used and the testing protocols implemented. The advantages and limitations of these methods have been discussed along with specific recommendations for their implementation and suggestions for incorporation into clinical practice.
Various treatment methods exist to treat obstructive sleep apnea (OSA); continuous positive airway pressure (CPAP) is considered the gold standard. It is however a clinical reality that the use of CPAP is often cumbersome. CPAP treatment is considered compliant when used ≥ 4 h per night as an average over all nights observed. Surgery, on the other hand, is regarded as successful when the apnea hypopnea index (AHI) drops at least 50% and is reduced below 20/h postoperatively in patients whose preoperative AHI was > 20/h. The effectiveness of CPAP compliance criteria can be questioned, just as the effectiveness of surgical success criteria has often been questioned.
The aim of the study was to compare non optimal use of optimal therapy (CPAP) with the continuous effect (100%) of often non optimal therapy (surgery).
Using mathematical function formulas, the effect on the AHI of various treatment modalities and their respective compliance and success criteria were calculated.
The more severe the AHI, the more percentage of total sleep time (TST) CPAP must be used to significantly reduce the AHI. Patients with moderate OSA reduce the AHI by 33.3% to 48.3% when using CPAP 4 h/ night (AHI 0-5, respectively). The required nightly percentage use rises as one reduces the AHI target to < 5. CPAP must be used 66.67% to 83.33% per night to reduce the AHI below 5 (AHI of 0 while using CPAP).
Using a mean AHI in CPAP therapy is more realistic than using arbitrary compliance rates, which, in fact, hide insufficient reductions in AHI.
Little is known regarding long-term patient compliance with the tennis ball technique (TBT), one of the original simple methods of positional therapy (i.e., avoiding the supine posture during sleep) for posture-dependent obstructive sleep apnea patients. The purpose of this study was to investigate long-term patient compliance with TBT.
A follow-up questionnaire was mailed to all patients prescribed TBT at the Adelaide Institute for Sleep Health between July 2004 and March 2008 (n = 108).
Sixty-seven patients replied to the questionnaire. Baseline demographic/clinical characteristics were not significantly different from non-respondents. Among the respondents, follow-up time was (mean +/- SD) 2.5 +/- 1.0 years. Four (6.0%) reported they were still using TBT (group A); 9 (13.4%) were no longer using TBT, claiming to have learned to avoid the supine position during sleep (group B); and 54 (80.6%) were neither using TBT nor avoiding the supine posture (group C). The main reason for ceasing TBT use in group C was that TBT was too uncomfortable (34/54 patients).
Long-term patient compliance with TBT appears to be very poor, with less than 10% of patients reporting continued use (group A) approximately 30 months after prescription. With most TBT non-compliers reporting it to be too uncomfortable, alternative forms of positional therapy appear to be needed.
Background:
Approximately half of obstructive sleep apnea (OSA) patients are positional (i.e., the majority of their breathing abnormalities during sleep appear in the supine posture). Little information exists as to whether avoiding the supine posture during sleep (positional therapy) is a valuable form of therapy for these patients.
Aim:
To assess the use of positional therapy (by the tennis ball technique [TBT]) during a 6 month period in 78 consecutive positional OSA patients.
Methods:
Demographic, polysomnographic, and self-reported questionnaire data on the use of the TBT were analyzed.
Results:
Of the 50 patients who returned the questionnaire, 19 (38%) (group A) said they were still using the TBT, and 12 (24%) (group B) said they used it initially and stopped using it within a few months but were still avoiding the supine position during sleep. Nineteen patients (38%) (group C) stopped using the TBT within a few months but did not learn how to avoid the sleep supine posture. Patients still using the TBT showed a significant improvement in their self-reported sleep quality (P < .005) and daytime alertness (P < .046) and a decrease in snoring loudness (P < .001). Patients of groups A and B were older than patients who did not comply with this therapy (P < .001). The main reason for patients stopping the use of the TBT in group C was that using it was uncomfortable.
Conclusions:
Positional therapy appears to be a valuable form of therapy mainly for some older aged positional OSA patients.
Positional therapy that prevents patients from sleeping supine has been used for many years to manage positional obstructive sleep apnea (OSA). However, patients' usage at home and the long term efficacy of this therapy have never been objectively assessed.
Sixteen patients with positional OSA who refused or could not tolerate continuous positive airway pressure (CPAP) were enrolled after a test night study (T0) to test the efficacy of the positional therapy device. The patients who had a successful test night were instructed to use the device every night for three months. Nightly usage was monitored by an actigraphic recorder placed inside the positional device. A follow-up night study (T3) was performed after three months of positional therapy.
Patients used the device on average 73.7 ± 29.3% (mean ± SD) of the nights for 8.0 ± 2.0 h/night. 10/16 patients used the device more than 80% of the nights. Compared to the baseline (diagnostic) night, mean apnea-hypopnea index (AHI) decreased from 26.7 ± 17.5 to 6.0 ± 3.4 with the positional device (p<0.0001) during T0 night. Oxygen desaturation (3%) index also fell from 18.4 ± 11.1 to 7.1 ± 5.7 (p = 0.001). Time spent supine fell from 42.8 ± 26.2% to 5.8 ± 7.2% (p < 0.0001). At three months (T3), the benefits persisted with no difference in AHI (p = 0.58) or in time spent supine (p = 0.98) compared to T0 night. The Epworth sleepiness scale showed a significant decrease from 9.4 ± 4.5 to 6.6 ± 4.7 (p = 0.02) after three months.
Selected patients with positional OSA can be effectively treated by a positional therapy with an objective compliance of 73.7% of the nights and a persistent efficacy after three months.
Obstructive sleep apnea is common, but access to diagnosis remains limited. Telemedicine may allow greater access to care; however, its effect on patient satisfaction and treatment adherence is unknown. This study compares patient satisfaction and continuous positive airway pressure (CPAP) adherence of patients seen by videoconference with those seen in person.
New patients seen via video or in person at a sleep center completed a survey, with three questions pertaining to satisfaction with the provider. Questions were scored 1-5; the sum was the patient satisfaction score. CPAP adherence was retrospectively analyzed in patients who met the physician via video or in person. Percentage of nights CPAP was used for ≥4 h and average minutes of CPAP use per night over 2 consecutive weeks were compared.
A Mann-Whitney test compared patient satisfaction of the 90 subjects (of whom, 56 met physician in person and 34 via video). Mean scores (in person, 14.82; video, 14.91; p=0.851) did not differ between groups. Mann-Whitney tests compared CPAP adherence in the 172 subjects (of whom, 111 met physician in person and 61 via video). Mean percentage of nights CPAP was used ≥4 h (in person, 71%; video, 65%; p=0.198) and the average minutes per night of CPAP use (in person, 340.55; video, 305.31; p=0.153) did not differ between groups.
The findings indicate that patients were equally satisfied with their provider and adherent to CPAP treatment whether they were seen in person or via video. Videoconferencing may improve access to patient care without reducing patient satisfaction or treatment adherence.
This study questioned whether level of arousal decreases as an inverse function of the number of sensory modalities continuously stimulated. 24 1-month-old infants served as Ss under 5 different conditions: no extra stimulation (control condition) and continuous stimulation of 1, 2, 3, and 4 sensory modalities. The 4 types of stimulation were auditory, visual, proprioceptive-tactile (swaddling), and temperature. Indices of arousal level included state, heart rate, respiration regularity, and gross motor activity. Results reaffirmed the pacifying effect of continuous stimulation, indicated that the effect is not restricted to 1 sensory modality but is instead a general characteristic of sensory stimulation in early development, and, finally, demonstrated that the pacification effect is indeed cumulative across modalities. Theoretical and practical aspects of these results are discussed.
Polysomnograms (PSGs) are routinely ordered by nonsleep specialists. However, it is unknown whether a sleep specialist consultation prior to a diagnostic PSG influences adherence to continuous positive airway pressure (CPAP) therapy.
This study was done at the University of Chicago Sleep Disorders Center and included 403 patients with obstructive sleep apnea who had CPAP adherence data available. CPAP was set up at home, and objective adherence was remotely monitored during the first 30 days of therapy. Physicians who ordered PSGs were divided into two groups: sleep specialists and nonsleep specialists.
Patients were aged 52.5 ± 14 years, 47% were men, and 54% were African American. Mean daily CPAP use was greater in patients who were referred by sleep specialists (n = 105, 279 ± 179 min/d) than in patients referred by nonsleep specialists (n = 298, 219 ± 152 min/d, P = .005). In the linear regression model adjusting for several covariates, only two predictors were significantly associated with CPAP adherence. A sleep specialist consultation prior to the diagnostic PSG was associated with 58.2 min more per day (P = .002), and African American race was associated with 56.0 min less per day (P = .002) of CPAP use.
In this cohort study, CPAP adherence was significantly higher with a sleep specialist consultation prior to the diagnostic PSG. In addition, African American race was associated with worse adherence to therapy. A better understanding of predictors of CPAP adherence may be useful in identifying patients who may benefit from a sleep specialist consultation prior to ordering a diagnostic PSG.
Obstructive sleep apnea (OSA) is common in stroke patients and is associated with poor functional outcome. The effects of positional therapy in ischemic stroke patients with OSA have not been investigated. We tested the hypothesis that ischemic stroke patients have less severe OSA during positional therapy that promotes nonsupine positioning.
We conducted a randomized, controlled, cross-over study. Sleep apnea screening studies were performed on two consecutive nights, using a portable respiratory monitoring system, on 18 subjects within the first 14days of ischemic stroke. An apnea-hypopnea index (AHI) ⩾5 established the diagnosis of OSA. Subjects were randomized to positional therapy that included the use of a therapeutic pillow on either the first or second night. On the control night, subjects used the hospital pillow and were positioned ad lib. Treatment effect on AHI was estimated using a repeated measures model.
All ischemic stroke subjects studied had OSA. The predominantly male group had a median age of 58years, BMI of 29kg/m(2), NIH Stroke Scale score of 3, and a median AHI on the nontherapeutic night of 39 (interquartile range: 21-54). Positional therapy reduced the amount of supine positioning by 36% (95% CI: 18-55% (P<0.001)). The AHI was reduced by 19.5% (95% CI: 4.9-31.9% (P=0.011)), when using positional therapy compared to sleeping ad lib.
Positional therapy to avoid supine positioning modestly reduces sleep apnea severity after ischemic stroke, and may therefore improve outcomes.
Continuous positive airway pressure (CPAP) is the most widely prescribed treatment for obstructive sleep apnoea syndrome (OSAS). Although it has been shown to improve the symptoms of OSAS, many patients have difficulty adhering to this treatment. The purpose of this study was to investigate the effectiveness of an automated telemedicine intervention to improve adherence to CPAP.
A randomised clinical trial was undertaken in 250 patients being started on CPAP therapy for OSAS. Patients were randomly assigned to use a theory-driven interactive voice response system designed to improve CPAP adherence (telephone-linked communications for CPAP (TLC-CPAP), n=124) or to an attention placebo control (n=126) for 12 months. TLC-CPAP monitors patients' self-reported behaviour and CPAP-related symptoms and provides feedback and counselling through a structured dialogue to enhance motivation to use CPAP. A Sleep Symptoms Checklist, the Functional Outcomes of Sleep Questionnaire, the Center for Epidemiological Studies Depression Scale and the Psychomotor Vigilance Task were administered at study entry and at 6-month and 12-month follow-up. Hours of CPAP usage at effective mask pressure were measured by the CPAP device stored in its memory and retrieved at each visit.
Median observed CPAP use in patients randomised to TLC-CPAP was approximately 1 h/night higher than in the control subjects at 6 months and 2 h/night higher at 12 months. Using generalised estimating equation modelling, the intervention had a significant effect on CPAP adherence. For secondary analysis, the effect of CPAP adherence on the secondary outcomes was analysed. CPAP adherence was significantly associated with a greater reduction in sleep apnoea symptoms and depressive symptoms and a greater improvement in functional status. No significant association was observed between CPAP adherence and reaction time.
The TLC-CPAP intervention resulted in improved CPAP adherence, which was associated with improved functional status and fewer depressive symptoms. CLINICAL TRIAL.GOV: NCT00232544.
Sixty male patients all with apnea plus hypopnea indices (A + HI) above 12.5, who met a criterion of positionality by having two or more times the rate of these events during supine sleep in comparison to their lateral sleep rate, were randomly assigned to one of four treatments for 8 weeks. All were restudied for two nights, one with and one without treatment devices. On treatment more than half the patients in each group reduced their A + HI to within normal limits and a third remained WNL without the use of devices. Half of those trained to sleep in the lateral position with the help of an alarm maintained this learning without the alarm as did half of those who were encouraged to learn this sleep posture on their own. There is an additive effect for the positional patient from wearing a tongue retaining device (TRD) if they continue to sleep in the supine position. Factors associated with successful treatment include overall severity, severity in the lateral position, weight, weight change, nasal patency and motivation to help their condition.
Despite the prevalence of sleep complaints among psychiatric patients, few questionnaires have been specifically designed to measure sleep quality in clinical populations. The Pittsburgh Sleep Quality Index (PSQI) is a self-rated questionnaire which assesses sleep quality and disturbances over a 1-month time interval. Nineteen individual items generate seven "component" scores: subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medication, and daytime dysfunction. The sum of scores for these seven components yields one global score. Clinical and clinimetric properties of the PSQI were assessed over an 18-month period with "good" sleepers (healthy subjects, n = 52) and "poor" sleepers (depressed patients, n = 54; sleep-disorder patients, n = 62). Acceptable measures of internal homogeneity, consistency (test-retest reliability), and validity were obtained. A global PSQI score greater than 5 yielded a diagnostic sensitivity of 89.6% and specificity of 86.5% (kappa = 0.75, p less than 0.001) in distinguishing good and poor sleepers. The clinimetric and clinical properties of the PSQI suggest its utility both in psychiatric clinical practice and research activities.
This study compared the effects of three auditory background conditions—no sound, intermittent sound, and continuous sound—on level of arousal in infants. The study also investigated responsiveness to discrete auditory stimuli superimposed upon these background conditions. The results indicated that level of arousal was decreased by continuous sound and increased by intermittent sound, relative to the no sound condition. Measures of level of arousal included state, respiration, heart rate, and motor activity. Responsiveness to discrete auditory stimuli, superimposed upon the background conditions and measured by evoked responses, was not predictable from indices of arousal level.
IN PREVIOUS studies [l] it has been established that a cluster of social events requiring change in ongoing life adjustment is significantly associated with the time of illness onset. Similarly, the relationship of what has been called ‘life stress,’ ‘emotional stress,’ ‘object loss,’ etc. and illness onset has been demonstrated by other investigations [2-131. It has been adduced from these studies that this clustering of social or life events achieves etiologic significance as a necessary but not sufficient cause of illness and accounts in part for the time of onset of disease. Methodologically, the interview or questionnaire technique used in these studies has yielded only the number and types of events making up the cluster. Some estimate of the magnitude of these events is now required to bring greater precision to this area of research and to provide a quantitative basis for new epidemiological studies of diseases. This report defines a method which achieves this requisite. METHOD
Obstruction of the upper airway during sleep (OSAS) is widely treated by having patients self-administer nasal continuous positive airway pressure (CPAP). To obtain objective evidence of the patterns of CPAP use, information was gathered from two urban sites on 35 OSAS patients who were prescribed CPAP for a total of 3,743 days. Patients were given CPAP machines that contained a microprocessor and monitor that measured actual pressure at the mask for every minute of each 24-h day for an average of 106 days per patient. They were not aware of the monitor inside the CPAP machines. Monitor output was compared with patients' diagnostic status, pretreatment clinical and demographic characteristics, and follow-up self-reports of CPAP use, problems, side effects, and aspects of daytime fatigue and sleepiness. Patients attempted to use CPAP an average of 66 +/- 37% of the days monitored. When CPAP was used, the mean duration of use was 4.88 +/- 1.97 h. However, patients' reports of the duration of CPAP use overestimated actual use by 69 +/- 110 min (p < 0.002). Both frequency and duration of CPAP use in the first month reliably predicted use in the third month (p < 0.0001). Although the majority (60%) of patients claimed to use CPAP nightly, only 16 of 35 (46%) met criteria for regular use, defined by at least 4 h of CPAP administered on 70% of the days monitored. Relative to less regular users, these 16 patients had more years of education (p = 0.05), and were more likely to work in professional occupations.(ABSTRACT TRUNCATED AT 250 WORDS)
This article summarizes the results of 153 studies published between 1977 and 1994 that evaluated the effectiveness of interventions to improve patient compliance with medical regimens.
The compliance interventions were classified by theoretical focus into educational, behavioral, and affective categories within which specific intervention strategies were further distinguished. The compliance indicators broadly represent five classes of compliance-related assessments: (1) health outcomes (eg, blood pressure and hospitalization), (2) direct indicators (eg, urine and blood tracers and weight change), (3) indirect indicators (eg, pill count and refill records), (4) subjective report (eg, patients' or others' reports), and (5) utilization (appointment making and keeping and use of preventive services). An effect size (ES) r, defined as Fisher's Z transformation of the Pearson correlation coefficient, representing the association between each intervention (intervention versus control) and compliance measure was calculated. Both an unweighted and weighted r were calculated because of large sample size variation, and a combined probability across studies was calculated.
The interventions produced significant effects for all the compliance indicators (combined Z values more than 5 and less than 32), with the magnitude of effects ranging from small to large. The largest effects (unweighted) were evident for refill records and pill counts and in blood/urine and weight change studies. Although smaller in magnitude, compliance effects were evident for improved health outcomes and utilization. Chronic disease patients, including those with diabetes and hypertension, as well as cancer patients and those with mental health problems especially benefited from interventions.
No single strategy or programmatic focus showed any clear advantage compared with another. Comprehensive interventions combining cognitive, behavioral, and affective components were more effective than single-focus interventions.
The literature on sensory perception during sleep suggests that light sleep (Stage 2) is more responsive to external sensory stimulation (e.g. sound, electrical shock) than deep sleep (Stages 3 and 4) and REM sleep. The main objective of this study was to characterize the specificity of nociceptive stimulation to trigger sleep arousal-awakening over all sleep stages. Thirteen healthy adults (e.g. without pain or sleep problems; six female and seven male of a mean age of 24.2+/-1.3 years) were included in the study. The responses to noxious intramuscular 5% hypertonic infusion were compared to innocuous vibrotactile and to respective control stimulations: isotonic infusion and auditory stimulations. These stimulations were applied during wakefulness and were repeated during sleep. Polygraphic signals (e.g. brain activity, heart rate) signals were recorded to score sleep arousal over all sleep stages. A subjective assessment of sleep quality was made on next morning. No overnight sensitization or habituation occurred with any of the experimental stimulations. The vibratory-auditory stimulations and the noxious hypertonic infusions triggered significantly (P < 0.05) more awakenings in sleep Stage 2 and in REM than their respective control stimulations. In sleep Stage 2, both vibratory + auditory stimulations and the noxious hypertonic infusions has the same awakening response frequency (approximately 30%), however, with the noxious infusions the response frequency were similar in sleep Stages 3 and 4 (P < 0.05) and in REM (trend). Compared to the baseline night, sleep quality was lower following the night with noxious stimulation (90.1+/-2.7 and 73.3+/-7.4 mm, respectively; P < 0.03. These data suggest that pain during sleep could trigger a sleep awaking response over all sleep stages and not only in light sleep.
The role of arousals in sleep is gaining interest among both basic researchers and clinicians. In the last 20 years increasing evidence shows that arousals are deeply involved in the pathophysiology of sleep disorders. The nature of arousals in sleep is still a matter of debate. According to the conceptual framework of the American Sleep Disorders Association criteria, arousals are a marker of sleep disruption representing a detrimental and harmful feature for sleep. In contrast, our view indicates arousals as elements weaved into the texture of sleep taking part in the regulation of the sleep process. In addition, the concept of micro-arousal (MA) has been extended, incorporating, besides the classical low-voltage fast-rhythm electroencephalographic (EEG) arousals, high-amplitude EEG bursts, be they like delta-like or K-complexes, which reflects a special kind of arousal process, mobilizing parallely antiarousal swings. In physiologic conditions, the slow and fast MA are not randomly scattered but appear structurally distributed within sleep representing state-specific arousal responses. MA preceded by slow waves occurs more frequently across the descending part of sleep cycles and in the first cycles, while the traditional fast type of arousals across the ascending slope of cycles prevails during the last third of sleep. The uniform arousal characteristics of these two types of MAs is supported by the finding that different MAs are associated with an increasing magnitude of vegetative activation ranging hierarchically from the weaker slow EEG types (coupled with mild autonomic activation) to the stronger rapid EEG types (coupled with a vigorous autonomic activation). Finally, it has been ascertained that MA are not isolated events but are basically endowed with a periodic nature expressed in non-rapid eye movement (NREM) sleep by the cyclic alternating pattern (CAP). Understanding the role of arousals and CAP and the relationship between physiologic and pathologic MA can shed light on the adaptive properties of the sleeping brain and provide insight into the pathomechanisms of sleep disturbances. Functional significance of arousal in sleep, and particularly in NREM sleep, is to ensure the reversibility of sleep, without which it would be identical to coma. Arousals may connect the sleeper with the surrounding world maintaining the selection of relevant incoming information and adapting the organism to the dangers and demands of the outer world. In this dynamic perspective, ongoing phasic events carry on the one hand arousal influences and on the other elements of information processing. The other function of arousals is tailoring the more or less stereotyped endogenously determined sleep process driven by chemical influences according to internal and external demands. In this perspective, arousals shape the individual course of night sleep as a variation of the sleep program.
Obstructive sleep apnea (OSA) is a prevalent and serious medical condition characterized by repeated complete or partial obstructions of the upper airway during sleep and is prevalent in 2% to 4% of working middle-aged adults. Nasal continuous positive airway pressure (CPAP) is the gold-standard treatment for OSA. Because compliance rates with CPAP therapy are disappointingly low, effective interventions are needed to improve CPAP compliance among patients diagnosed with OSA.
The aim was to determine whether wireless telemonitoring of CPAP compliance and efficacy data, compared to usual clinical care, results in higher CPAP compliance and improved OSA outcomes.
45 patients newly diagnosed with OSA were randomized to either telemonitored clinical care or usual clinical care and were followed for their first 2 months of treatment with CPAP therapy. CPAP therapists were not blinded to the participants' treatment group.
20 participants in each group received the designated intervention. Patients randomized to telemonitored clinical care used CPAP an average of 4.1 +/- 1.8 hours per night, while the usual clinical care patients averaged 2.8 +/- 2.2 hours per night (P = .07). Telemonitored patients used CPAP on 78% +/- 22% of the possible nights, while usual care patients used CPAP on 60% +/- 32% of the nights (P = .07). No statistically significant differences between the groups were found on measures of CPAP efficacy, including measures of mask leak and the Apnea-Hypopnea Index. Patients in the telemonitored group rated their likelihood to continue using CPAP significantly higher than the patients in the usual care group. Patients in both groups were highly satisfied with the care they received and rated themselves as "not concerned" that their CPAP data were being wirelessly monitored.
Telemonitoring of CPAP compliance and efficacy data and rapid use of those data by the clinical sleep team to guide the collaborative (ie, patient and provider) management of CPAP treatment is as effective as usual care in improving compliance rates and outcomes in new CPAP users. This study was designed as a pilot-larger, well-powered studies are necessary to fully evaluate the clinical and economic efficacy of telemonitoring for this population.
Treating the positional obstructive sleep apnea with a vest preventing the supine position is well known to be riskless and inexpensive. It was the aim of this study to test the efficacy and, for the first time, the longterm compliance of this treatment.
14 patients with positional obstructive sleep apnea (age 48.2 +/- 12.1 years; body-mass-index: 28.1 +/- 4.6 kg/m2 mean, +/- SD) were investigated polysomnographically without and with a vest preventing the supine position. 13.7 +/- 15.9 months later the patients were asked about the comfort of the vest and the nocturnal using time using the Likert-scale, and data about the latest Epworth Sleepiness Scale (ESS) was collected.
The respiratory disturbance index (RDI) was reduced statistically significant from 31.3 +/- 12.9/h to 13.8 +/- 9.0/h by wearing the vest (p < 0.001). Total sleep time at an oxygen saturation below 90% decreased from 8.2 +/- 7.1% to 3.8 +/- 4.5% (p < 0.001), the snoring time from 15.4 +/-19.6 % to 9.8 +/-13.1% (p < 0.05) of the total sleep time (TST) and the arousal index from 23.1 +/-16.0/h to 18.6 +/-11.4/h (p < 0.05). 24 +/-28.8 months later 28.6% of the patients were still using the vest. Of these patients the ESS decreased from 8.5 +/-3.2 to 6.5 +/-2.9 (p < 0.05). 72.4% of the patients refused the longterm therapy with the vest because of its low wearing comfort.
Although the vest approved to be effective against positional obstructive sleep apnea, the longterm compliance is low because of its need getting used to.
Experiencing sensation and perception
- J H Krantz
Progress in vibrotactile threshold evaluation
- M S Gandhi
- R Sesek
- R Tuckett
- Morris Bamberg
- MS Gandhi
Poor long-term compliance with the tennis ball technique for treating positional obstructive sleep apnea
- J J Bignold
- JJ Bignold